2010aa1cdemcurinnbeyondclerkship

							CDEM Innovations in Curricular
       Development:
  Moving Beyond The Clerkship

      Nicholas E. Kman, MD
        David Gordon, MD
       Session Format
1 hour Panel Discussion
Quick Literature and Listserve Review
10 minute Innovations Presentations
from panel:
 David Wald
 Kathy Hiller
 Joanne Oakes
  Innovations: Objectives
1. Expose participants to ways EM is
taught to students of all years.
2. Give ideas/ examples of how
educators gain exposure early in
medical school while allowing
participants opportunity to discuss.
3. Allow ample time for questions and
personal experience.
                           Background
       Traditionally, medical students were
       exposed to EM late in medical school
       (typically 4th year, if at all).
       EM Educators are pushing for
       involvement early in medical school.
       What opportunities exist for early
       exposure to medical students?
Russi CS, Hamilton GC. A Case for Emergency Medicine in the Undergraduate Medical
School Curriculum. Academic Emerg Med 2005. 12:994-998.
       Listserve Says…
EMIG
1st and 2nd year select lectures
Mentorship Programs
Physician Development Groups
(CAPS)
Procedures Electives (CSIE)
Annual Career Fair
                       Literature Says…
       EM elective
       Required clerkship/ Subinternship
       BLS, ACLS instruction
       EMS opportunities
       Simulation Electives


Coates WC. An Educator’s Guide to Teaching Emergency Medicine to Medical Students.
Acad Emerg Med 2004. 11:300-306.
                   Literature Says…
   Advanced EM elective
   Toxicology
   Pediatric EM
   Sports Medicine
   Ultrasound


Pacella CB. Advanced Opportunities for Student Education in Emergency Medicine. Acad
Emerg Med 2004. 11: 1028e9-e12.
                Literature Says…
International EM
Wilderness Medicine
Hyperbaric Medicine
Disaster Medicine
Geriatric EM
EM Research

Pacella CB. Advanced Opportunities for Student Education in Emergency Medicine.
Acad Emerg Med 2004. 11: 1028e9-e12.
      Panel Discussion
In past year, we solicited CDEM for
"Innovations in Medical Student
Curriculum Development“.
Received 7 entries and will be
presenting top 3 as voted on by CDEM
Education Program Committee.
This is 2nd annual session and plan to
make this a yearly event (with your
help!).
      Panel Discussion
To the presentations…
          Panel Discussion
Clinical Medicine Correlation Exercises Using a High
Fidelity Simulator to Enhance Basic Science Teaching
   David A. Wald, DO, FAAEM, FACEOP

Integrating Critical Care into a Mandatory EM Curriculum:
A Novel Approach to Longitudinal Experience
   Katherine M. Hiller, MD, FACEP


Vertical Integration of History and Physical Exam Skills by
EM Faculty
  Joanne L. Oakes, MD, FACEP
   CLINICAL MEDICINE CORRELATION
   EXERCISES USING A HIGH FIDELITY
SIMULATOR TO ENHANCE BASIC SCIENCE
              TEACHING

     Moving Beyond the Clerkship




            David A. Wald, DO
         CORD Academic Assembly
               March 2010
          Background
In 2007, charged with integrating
clinical concepts into basic science
course work within the framework of
our Doctoring course
Preclinical curriculum
 Problem based learning exercises
   Small group teaching – 15:2 ratio
   Incorporate a high fidelity simulator
   (SimMan®)
        Current Cases
MS I students
 Complete heart block
 Diabetic ketoacidosis
 Hemorrhagic shock
MS II students
 Asthma exacerbation
 Opioid overdose
 Ventricular tachycardia
 Presentations / Publications

Poster and Oral presentation
International Association of
Medical Science Educators
(IAMSE)
Salt Lake City, UT, June 2008
Blackboard Academic Suite
Doorway Information
    Case Implementation
1 hour exercise
 15-20 minute evaluation of SimMan®
   Alternative approaches based on set up of
   the simulation center
 Reconvene for debriefing and case
 discussion for remaining 40 minutes
Well Timed to Classroom Concepts
Educational Experience
Bridged the Gap
Simulation was Important and Useful
          Challenges
Large # of learners
 12 one hour sessions / class size of 180
Timing of sessions
Integration of simulation
Assessment of learner achievement
             Benefits
Small group teaching
Collaboration with basic scientists
Experience with simulation
Introduction to EM faculty
Opportunities for scholarship
Bridging the gap
Katherine Hiller, MD, FACEP
    University of Arizona
• University of Arizona College of Medicine
  had had no major curriculum revisions for
  over a decade
• The entire 4th year curriculum was elective
• Lack of both vertical and horizontal
  integration
• Institution-wide survey of faculty and
  students:
   – (1) What do all students need to know
     before they graduate?
   – (2) Who teaches/is able to teach what?
• Students need:
   – 180 clinical topics and diseases from
      ‘abdominal pain’ to ‘wound care’
   – Critical care heavily represented
• Emergency Medicine teaches/has the capacity to
  teach:
   – Nearly every single one
• In fact, we excel at many of the topics:
   – Acute pain management
   – Shock/sepsis
   – Overdose/ingestions
• Students need…longitudinal experiences
• Students need…multidisciplinary
  experiences
• Students need…Emergency Medicine
• Students need…Critical Care

• What about an EM/Critical Care rotation?
• Didactics
   – Small group case-based discussions
   – Small group labs
   – Large group conferences
• Self-directed learning
   – On-line learning modules
   – Critical care workbook
• Clinical shifts (12 x 8-hour shifts) at 3 clinical sites
• Critical care rotation/rounds
• Exam
• Students identify a critical care patient in the
  ED during their day shift (6 am – 2 pm)
• Students present the case on sign-out teaching
  rounds in the ICU (5 pm)
• Students follow their patient in the ICU for the
  next 4-5 days
   – presenting on rounds
   – creating a management plan
   – following response to treatment
Day        6:00     7:00     8:00 9:00 10:00 11:00 12:00         1:00     2:00    3:00   4:00     5:00   6:00   7:00   8:00   9:00     10:00
            AM       AM       AM      AM AM    AM    PM           PM       PM      PM     PM       PM     PM     PM     PM     PM        PM
                           Orientation
       1
                  EM Residents                                 Pulm/Critical Care
       2          conference                                   conference
                         Orientation
       3
         Day shift--identify critical care                                                      Sign out
       4 patient                                                                                rounds--ICU
         Day shift--identify critical care                                                      Sign out
       5 patient                                                                                rounds--ICU
                                  (8:30) ICU teaching   Independent                             Sign out
       6                          rounds                learning/workbook                       rounds--ICU
                                  (8:30) ICU teaching   Independent                             Sign out
       7                          rounds                learning/workbook                       rounds--ICU
                                  (8:30) ICU teaching   Independent                             Sign out
       8                          rounds                learning/workbook                       rounds--ICU
                 EM Residents                                  Pulm/Critical Care
       9         conference                                    conference
                                                                      Swing shift
      10
                                                                        Swing shift
      11
                                                                                                                                     Night
      12                                                                                                                             shift
                                                                                                                                     Night
      13                                                                                                                             shift
• Students complete a workbook using their
  ED patient (and others if necessary) in the
  ICU
   – Focus on how the ED management of
     their patient affected his critical care
     course
•   Ventilator management
•   Sepsis
•   Vasopressor management
•   Social/psychological issues in the ICU
•   Miscellaneous ICU issues (nosocomial
    infections, prophylaxis, sedation/restraints,
    etc)
• Students complete the workbook by
  reviewing cases with at least three
  individuals from different disciplines
   – Critical care fellows and staff
   – Nursing staff
   – Respiratory therapists
   – Pharmacists
   – Social workers/case managers
• 12 clinical EM shifts total in a 4-week block
   – Average number of shifts in EM
     clerkships is 15; IQR 14-16 (Wald et al,
     Acad Emerg Med 2007)
• Also offered: an EM Acting-Internship for
  career-track students if students would like
  additional EM experience
• 80 hours per week averaged over 4 weeks
   – Orientation (16 hours)
   – 12 x 8 hour shifts (96 hours)
   – EM and Pulmonary conferences: 7
     hours/week (28 hours)
   – Critical care time: 10 hours x 3 days; 2
     hours x 2 days (34 hours)
• Total: 167 hours (~42 hours/week)
• *Still have to ensure 10 hours off between
  clinical duties/shifts
• Currently in development: students have
  the option to pick a “track” and focus their
  ICU experience
• In addition to core ICU learning objectives
   – Trauma ICU-specific objectives
   – Pediatric ICU-specific objectives
• Integrating critical care via a longitudinal
  experience emphasizes the importance of a
  patient’s Emergency Department care on
  their hospital course.
Special thanks to Dr. Kevin Reilly, MD and
          Dr. Laura Meinke, MD
     Innovations in Curriculum
          Development:
Vertical Integration of History and Physical Skills
  Curriculum by Emergency Medicine faculty




        CDEM CORD Academic Assembly
                March 2010
                   Background
• History and Physical examination skills are
  taught in the first and/or second year
  curriculum of medical schools
     • Traditionally by Internal Medicine or Family Medicine
       faculty
• Third year clerkships are specialty specific
• Fourth year rotations focus on patient
  management skills
               Background
• Communication between specialties and
  between training years may be inconsistent
  regarding goals, objectives, methods,
  expectations, and outcomes for student
  performance
• Emergency Medicine physician educators are
  uniquely able to provide multispecialty,
  multidisciplinary skill training
                 Objectives

• Create a cohesive, standardized, vertically
  integrated, multidisciplinary curriculum for
  acquisition of history and physical
  examination skills for the University, focusing
  on the evaluation of the undifferentiated
  patient and clinical decision making skills
 Strengths: What We Already Had
• EM Physician created “Clinical Applications”
  course for MSIs with all other first year basic
  science course directors (all PhDs), which uses
  clinical scenarios integrating basic science
  content
     • Team Based Learning small groups
     • 7 cases dispersed throughout the year
     • Focus on clinical decision making
 Strengths: What We Already Had
• EM Physician created the “Technical Skills
  Course” for the University for all MSIIs prior to
  entering clerkships
     •   BLS certification
     •   Vascular access
     •   Lumbar punctures
     •   Order writing
     •   Foleys, NG tubes
  Curriculum Overview: What We
           Already Had
• MSI: Introduction to Clinical Medicine (ICM)
• MSII: Physical Diagnosis (PD)
• End of third year Comprehensive Clinical
  Competency Examination (CCCE) Committee
• Surgical and Clinical Skills Center (SCSC)
• Supportive administration
The Surgical And Clinical Skills Center
 •14 examination rooms with AV monitoring, computer systems
 •Standardized patients available for all years of medical student
 training
                                      MS1 ICM Skills
   The “Well” Patient Comprehensive History and      Comprehensive Hx, Focused Hx, and Comprehensive
               Physical, SCSC patients                            Physical examinations




                          MS2 Physical diagnosis Skills
All System “abnormals”     GYN, Breast, GU, Ophth,
with signs and symptoms      Rheum, Derm skill           Preceptorships        OSCE and NBME exam
        of disease                sessions




        MS3 Clerkships with CCCE at the end of 3rd year
                   Challenges
• Communication
    • Between courses and projects
    • Between course directors
    • Between training years and specialties
• Content
    • Why don’t we all do this the same way?
    • “We have always done it this way”
• Outcomes
    • Performance measures?
                   Back to Basics
• Defining goals and objectives: the pocket
  guide
     •   How to take a history
     •   How to adapt a history for different types of patients
     •   Standard comprehensive physical examination skills
     •   Basis for content revision of ICM and PD


• Multidisciplinary agreement of standard
  definitions and techniques
                   The Process
• Standardized patient training
     • They are the real “glue” between all training years in our
       institution
• Course director input and agreement
     • Faculty training sessions, Curriculum Committee sessions
• Performance examination revisions
     • ICM, PD OSCE, CCCE
• Clerkship director input and agreement from
  all specialties
            Outcome Measures
• Comparative data collection is ongoing
     • Standardized course performance examinations (MSI)
        • 3 years of data
     • OSCE examination (MSII)
        • 2 years of data*
     • CCCE examination (MSIII)
        • 1st year of data
     • Clerkship performance faculty reviews
     • Clinical Skills step II national board examination*
                  Outcomes
• Student responses
• Faculty responses
• Positive collaboration among educators and
  faculty members from all specialties across
  training years
     • Projects
     • Research
     • Teaching
          Challenges
• TIME
• MONEY
                Prior Work References
•   Roger J. Bick, FAHA, MIBiol, Joanne L. Oakes, M.D., Jeffrey K. Actor, Ph.D., Leonard
    J. Cleary, Ph.D., Daniel Felleman, Ph.D., Allison R. Ownby, Ph.D., Norman W.
    Weisbrodt, Ph.D., Rebecca L. Cox, Ph.D., Nachum Dafny, Ph.D. and William E.
    Seifert, Jr., Ph.D. Integrative Teaching: Problem Solving and Integration of Basic
    Science Concepts into Clinical Scenarios using Team-Based Learning. JIAMSE
    19:126-134, 2009.
•   Seifert WE, Actor JA, Bick RJ, Cleary LJ, Cox R, Dafny N, Felleman D, Johansson W,
    Green E, Ownby A, Weisbrodt N, and Oakes J. Clinical Applications: Problem
    Solving and Integration of Basic Science Concepts Using Team-Based Learning.
    JIAMSE. 2008;18:1S4.
•   Leonard Cleary Ph.D., Edie Shulman M.D., and Joanne Oakes M.D. Integration of
    Anatomy and Introduction to Clinical Medicine. Presented at the American
    Association of Clinical Anatomists’ annual meeting, July 2008.
Questions for the Panel
          Conclusions
There is ample opportunity to get
involved with underclassmen.
Early involvement may improve
interest in specialty.
Look for opportunities in Simulation,
Introduction to Clinical Medicine
(ICM), and Doctoring courses.
Change the paradigm!
 Curricular Innovations
Thank you for attending.
Thanks to Sorabh Khandelwal and the
program committee for help with
selections.
Watch your e-mail to see how you can
participate next year!